Annals of Clinical Case Reports Research Article

Published: 11 Jul, 2022

Evaluate the Existing Integration of Sexual Reproductive

Health Services with HIV Treatment in Oromia Regional
State, Ethiopia
Dereje Bayissa Demissie1,2* and Rose Mmusi-Phetoe3
1
Department of Health Studies, University of South Africa, South Africa
2
St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
3
Department of Public Health, College of Human Science, University of South Africa, South Africa

Abstract
In settings where high, HIV prevalence and unmet need for sexual and reproductive health services
is critical to reducing HIV transmission and maternal mortality in a resource-limiting area,
integration of these services are very crucial. The study aimed to evaluate the existing ‘integration of
sexual reproductive health services with HIV services.
Methods: A Health facility-based cross-sectional study design was conducted with multiple
data collection approaches was used to collect data from women living with HIV attending ART
clinics. Self-administrated interview questionnaires were used to collect data from supervisors,
health managers, and healthcare providers by the total census of 16 ART/PMTC services provide,
supervisors, and 15 Health offices/Bureau managers, and randomly selected 654 Women Living
with HIV (WLHIV) for the study. The collected data were analyzed by SPSS.
Result: This study assessed the existing ‘integration of sexual reproductive health services with
HIV treatment for women living with HIV and attending ART in Oromia Region, Ethiopia. Such
OPEN ACCESS integration ranged from the provision of maternal, family planning, neonatal health services, and
health education on sexual reproductive health combined with HIV services for women living
*Correspondence:
with HIV. Almost all respondents (n=635, 97.1%) preferred integrated sexual reproductive health
Dereje Bayissa Demissie, Department
and HIV services at the same facility. Also, most of the providers (n=622, 95%), were in favor of
of Health Studies, University of ‘integrated family planning’/HIV services. The current study revealed that the integration of family
South Africa, and St. Paul's Hospital planning with HIV services includes counseling on available family planning methods in the ART
Millennium Medical College, Addis room, to the provision of ‘family planning methods such as condoms, pills, injectable methods,
Ababa, Ethiopia, implants in the ART rooms, and referrals for long-acting and permanent methods.
E-mail: [email protected]
Conclusion: These study findings showed considerable disparities between the availability of
Received Date: 11 May 2022
elements of integrated family planning/HIV services, and the actual delivery of sexual reproductive
Accepted Date: 05 Jul 2022
health services that are fully integrated; where both HIV- and family planning-related elements are
Published Date: 11 Jul 2022
incorporated into the visit.
Citation:
Demissie DB, Mmusi-Phetoe R. Abbreviations
Evaluate the Existing Integration of
AIDS: Acquired Immune Deficiency Syndrome; ART: Antiretroviral Therapy; AOR: Adjusted
Sexual Reproductive Health Services
Odd Ratio; CSA: Central Statistical Agency; CI: Confidence Interval; COR: Crude Odd Ratio; FHI:
with HIV Treatment in Oromia Regional
Family Health International; FMOH: Federal Ministry of Health; HIV: Human Immunodeficiency
State, Ethiopia. Ann Clin Case Rep.
Virus; IUD: Intra-Uterine Devices; MOH: Ministry of Health; MNCH: Maternal Neonatal Child
2022; 7: 2244.
Health; PMTC: Prevention of Mother to Child Transmission of HIV; OR: Odds Ratio; ORHB:
ISSN: 2474-1655
Oromia Regional Health Bureau; SPHMMC: Saint Paul's Hospital Millennium Medical College;
Copyright © 2022 Dereje Bayissa STIs: Sexually Transmitted Infections; WLHIV: Women Living with HIV; UNAIDS: United Nations
Demissie. This is an open access Program on HIV/AIDS; UNICEF: United Nations International Children's Emergency Fund;
article distributed under the Creative UNISA: University of South Africa; USAID: United States Agency for International Development;
Commons Attribution License, which WHO: World Health Organization
permits unrestricted use, distribution,
and reproduction in any medium,
Introduction
provided the original work is properly Maternal deaths among women living with HIV are mostly attributed to indirect obstetric causes,
cited. particularly non-pregnancy-related infections [1]. The ‘Sustainable Development Goals (SDGs)

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Sexual Health

recommendations, member countries should ‘ensure universal access conducted with quantitative data collection approach was used to
to sexual and reproductive healthcare services, and the integration of collect data from ‘women living with HIV’ attending ART clinics.
reproductive health into national strategies and programs by the end
Sample size determination
of 2030’ [2]. According to a study by Kendall and Danel [2] integration
of health service delivery is key to addressing improvements in The sample size was determined through a single population
MNCH services and ‘HIV care and treatment in sub-Saharan African proportion formula by using a case study found in integrated sites in
countries. Public health programs emphasize that the ‘integration Ethiopia, where 40% of women were family planning users (P) [7,8].
of family planning services with HIV treatment to increases dual By considering the design effect of 2, with correction formula since
contraceptive methods’ utilization will ensure protection from both the total population was less than 10,000 (2,380) and with a 5% non-
unintended pregnancy and STIs, including HIV/AIDS [3]. response rate considered, the final sample size was 670 women living
with HIV and healthcare providers, supervisors, and Health offices/
There were beneficial synergies in terms of increased ‘Sexually Bureau managers [9-12].
Transmitted Infection’ (STI) prevention, including syphilis screening
and treatment, and early childhood immunization [4]. Another peer- Sampling procedure
reviewed study illustrated how best to integrate other interventions, All hospitals and health centers found in the Special ‘Zone of
such as postpartum contraception or tuberculosis screening and Oromia Region ‘that provide ART services were identified and
treatment, into services that are already providing some parts of randomly selected by computer-generated methods to be included in
integrated HIV care for pregnant and postpartum women, which is the study. A list of all women living with HIV from each facility, aged
almost non-existent [5]. between 18 and 49 years of age, was randomly created. Study sites
were prepared and entered into SPSS version 23 by using their pre-
Statement of the problem
ART registration numbers from the Health Management Information
In 2013, the ‘United Nations Population Fund’ highlighted System (HMIS) database [12]. A simple random sampling technique
that the sexual and reproductive health rights agenda should be a by computer-generated samples was utilized at each health center to
key feature of the next development goals, in the ‘post-Millennium select 670 study respondents. The number of study respondents was
Development Goals’ era [6]. In 2015, the United Nations General allocated proportionally for the five health centers, based on their
Assembly on Sustainable Development Goals, the SDG 3, called for total number of ART clients [9-12].
countries to ensure healthy lives and promote wellbeing for all ages.
A total census of supervisors, supervisors, experts of Woreda,
The SDG 3.7 calls for member countries to ensure universal access
zonal and regional health bureau who were working in the MNCH and
to sexual and reproductive healthcare services, and the integration
HIV treatment prevention office, and healthcare providers working in
of reproductive health into national strategies and programs by 2030
the ART clinics of selected health facilities, were purposively included
[6]. Accordingly, the WHO [6] highlighted that universal access to
in the study.
reproductive health was a necessary condition for achieving the SDGs.
Meeting the unmet needs for family planning in sub-Saharan Africa Data collection
could make an important contribution to improving maternal health The questionnaire used for data collection was initially prepared
through early studies or initiatives. ‘Programs that have succeeded in in English, and translated to Afaan Oromo, and back to English for
promoting condom use and providing HIV prevention and treatment language experts to confirm its consistency. Finally, the corrected
services in this region have largely missed the opportunity to address Afaan Oromo version was used to collect the data from women
the contraceptive needs of the key populations they serve. Therefore, living with HIV attending ART clinics. The questions included in
the research statement for this study is “What is the status of existing the questionnaire were adapted and prepared by reviewing different
integration of sexual reproductive health services with HIV services related literature and variables identified to be measured. The training
for women of reproductive age living with HIV attending healthcare was given to data collectors and supervisors by the primary researcher
facilities in Oromia Region, Ethiopia? for two days. Data collectors cross-checked the pre-ART card
Methods numbers of women living with HIV who came to the ART clinic with
sampled card numbers daily. Five trained data collectors collected
Research setting data from women of reproductive age. The completed questionnaires
This study was conducted in the Oromia Region surroundings of were collected and checked daily for consistency and completeness
Finfinne Oromia, Ethiopia. Currently, there are 27 health centers with by supervisors and the primary researcher. Data were collected using
98.5% potential health service coverage. 13 health centers have been a ‘pre-tested structured Afaan Oromo version’ of the questionnaire.
providing ART and family planning services in the zone, of which A pre-test of the questionnaire was done on 5% of the women living
five were randomly selected as the study setting. The total number of with HIV at Ambo health center, to identify any ambiguity, to
‘people living with HIV enrolled at ART clinics’ in the zone was 9,421, confirm consistency in the questionnaire, to determine acceptability,
of which 2,380 were ‘women of reproductive age, and of these, 1,557 and to make necessary corrections one week before the actual data
were from five randomly selected health centers (Office Finfinne collection process [9,11,12]. The respondents were guided through
Special Zone 2018). The target population was HIV-positive women a questionnaire and chart abstraction conducted at their health
of reproductive age who had attended ART follow-up services for at facility by trained data collectors and Self-administrated structured
least six months from randomly selected healthcare facilities in the questionnaires were used to collect data from supervisors, healthcare
Oromia Region, Ethiopia. The accessible sample was 1,557 eligible providers, and Health offices/Bureau managers.
women of reproductive age living with HIV attending ART clinics in Data management and analysis
public health centers.
The ‘returned questionnaires were checked for completeness,
‘A Health facility-based cross-sectional study design was cleaned manually, coded and entered into EPI INFO 7.1.6 version, and

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then transferred to SPSS version 23 for further analysis. Frequencies, 16 ART/PMTC services provides were participated in the study,
percentages, mean and Standard Deviation (SD) was used to which gave the complete response rate of 100% (16/16) and 654/670
summarize descriptive statistics of the data and text. Moreover, tables (97.6%) for reproductive-age women living with HIV. There were 654
and graphs were used for data presentation [9,11,12]. respondents whose ages ranged between 18 and 49 years. The mean
age of the respondents was 31.86 years with an SD of ± 6.0 years
Result
(Table 1).
This study assessed the existing integration of family planning
services with HIV treatments, guidelines, policy, protocols and Existing integration of family planning and HIV services.
healthcare managers. The study also sourced information from the Integration of sexual reproductive health services with
healthcare providers in respect of the level of provision of both HIV HIV treatment
and family planning services in practice in the healthcare facilities. Out of a total number of women living with HIV in their
The findings in this regard are presented next. A total census of reproductive age (n=654), the majority (n=472, 72.0%) were attended
Table 1: Integration of sexual reproductive health services with HIV treatment for women living with HIV attending ART in Oromia, Ethiopia, 2018.
Integration of sexual reproductive health services - ART/PMTCT Services/Categories Frequency (%)

Family planning 157 (24)

TB screening and prophylaxis 8 (1.2)

Health facilities visited on the day of data collection HIV monitoring and treatment/AR follow up 471 (72.0)

PMTCT 13 (2.0)

Sickness for treatment 5 (0.8)

Family planning 233 (35.6)

Management of STI s 54 (8.3)

Services received on the day of data collection Maternal and new-born care 311 (47.6)

PMTCT 49 (7.5)

Others/TB screening and Rx 7 (1.1)

Yes 44 (6.7)
Referred to any other services
No 610 (93.3)

Family planning 198 (30.3)

Management of STI s 22 (3.4)

Maternal and new-born care 31 (4.7)

The need for other services on the day of data collection PMTCT 19 (2.9)

Condom services 181 (27.7)

HIV monitoring and treatment/AR follow up 155 (23.7)

Other specify 4 (0.6)

Prefer same facility/site 635 (97.1)

Preference for sexual reproductive health services and HIV services at
Prefer a different facility/site 6 (0.9)
the same facility
No preference 13 (2.0)

Reduce the number of trips to the facility 355 (54.3)

Improve the efficiency of services 336 (51.4)

Reduce transportation costs 360 (55.0)

Some possible benefits of receiving all these services from the same
Reduce Fees 141 (21.6)
facility at one time
Reduce waiting time 366 (56.0)

Good opportunity to access additional services 195 (29.8)

Reduce HIV-related stigma 332 (50.8)

Prefer the same provider 634 (96.9)

Preference for sexual reproductive health services and HIV services
Prefer referral to another provider 1 (0.2)
from the same provider
No preference 19 (2.9)

Family planning 349 (53.4)

Use of condoms to prevent unintended pregnancy 442 (67.6)

Healthcare provider provided health education on sexual reproductive Use of condoms to prevent HIV /STI 395 (60.4)
health services during data collection for clients during follow up HIV is treatable with ART 519 (79.4)

STI management 229 (35.0)

HIV prevention /PMTCT 249 (38.1)

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Table 2: Distribution of service providers in the ART clinic and PMTCT room in Oromia Ethiopia 2018.
Service providers Category Frequency (N) Percentage (%)

Holeta (A) 2 12.5

Burayu (B) 3 18.8

Health facilities Chancho (C) 5 31.3

Sululta (D) 4 25

Legatafo (E) 2 12.5

Male 8 50
Sex
Female 8 50

≤ 30 years 11 68.8
Age in years Mean age 34.19
≥ 31+ years 5 31.2

BSc nurse 7 43.8

Midwife (BSc) 1 6.3

Professional background
Midwife (Diploma) 3 18.8

Health officer 5 31.3

1 to 4 years 9 56.3
Work experiences
5 to 9 years 7 43.8

ART focal person 11 68.8

Title and role of respondent
PMTC focal person 5 31.2

Table 3: Essential sexual reproductive health services are offered and integrated with HIV services in Oromia Ethiopia 2018.
Sexual reproductive health integrated with
Categories Frequency (%) Yes Frequency (%) No
HIV services
Family planning 16 (100) 0 (0.0)

Prevention and management of STIs 16 (100) 0 (0.0)

Essential sexual reproductive health services
are offered at this facility Maternal and new-born care 14 (87.5) 2 (12.5)
Prevention and management of
7 (43.8) 9 (56.3)
gender-based violence
Category of essential sexual reproductive Offered 13 (81.2)
health services are offered at this facility Not offered 3 (18.8)

Family planning 16 (100) 0 (0.0)

Prevention and management of STI s 9 (56.3) 7 (43.8)

Essential sexual reproductive health services Maternal and new-born care 6 (37.5) 10 (62.5)
are integrated with HIV services at this facility
Prevention and management of
11 (68.8) 5 (31.2)
gender-based violence
Prevention of unsafe abortion and
12 (75) 4 (25)
management of post-abortion care
Category of essential sexual reproductive Integrated 9 (56.3)
health services are integrated with HIV
services at this facility Not Integrated 7 (43.8)
Health facility offer sexual reproductive health Located in the same service site 16 (100%) 0 (0.0)
services within HIV counseling and testing with the same provider
services Offered on the same day 16 (100%) 0 (0.0)

HIV monitoring and ART follow-up and received family planning reproductive health with HIV services from the same providers.
services. Respondents reported that 311 (47.6%) received maternal These respondents mentioned some possible benefits to receiving
and newborn care, and 233 (35.6%) were received family planning, all these services from the same facility during a single visit, such as
excluding those provided outside of the facility by referral. reduced wasted time (n=366, 56.0%), transportation costs (n=360,
55.0%), number of trips to the facility (n=355, 54.3%), and improved
Of all the respondents, only 44 (6.7%) were referred to any other
efficiency of services (n=336, 51.4%).
services, but 198 (30.3%) respondents mentioned a need to received
family planning services, 22 (3.4%) needed STI management, and Respondents stated that healthcare providers offered health
19 (2.9%) needed to received PMTCT services from those facilities education on major components of sexual reproductive health and
(Table 1). HIV services for women living with HIV during follow up, as follows;
HIV is treatable with ART (n=519, 79.4%), use of condoms to prevent
Of the total respondents, almost all (n=635, 97.1%) preferred HIV/STIs (n=395, 60.4%), use of condoms to prevent unintended
the integration of sexual reproductive health with HIV services at pregnancy (n=446, 67.6%), and family planning (n=349, 53.4%)
the same facility or site. Moreover, 96.9% preferred to receive sexual (Table 1).

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Table 4: HIV services provided in family planning and condom provision services in Oromia Ethiopia 2018.
HIV services Categories Frequency (%) Yes Frequency (%) No

Provider-initiated testing and counseling 8 (50) 8 (50)

Prophylaxis and treatment for people living with HIV
13 (81.3) 3 (18.8)
(OIs and HIV)
Home-based care 4 (25) 12 (75)

HIV services are provided in family planning Psycho-social support 8 (50) 8 (50)
services prevention for and by people living with HIV 13 (81.3) 3 (18.8)
HIV prevention information and services for general
16 (100) 0 (0.0)
population
Condom provision 15 (93.8) 1 (6.3)

PMTCT (four prongs) 13 (81.3) 3 (18.8)

Category HIV services provided within family Provided within family planning 9 (56.2)
planning service Not Provided within family planning 7 (43.8)

Family planning 16 (100) 0 (0.0)

Prevention and management of STI s 16 (100) 0 (0.0)

Sexual reproductive health services provided
in condom provision services Maternal and new-born care 8 (50) 8 (50)
Prevention and management of gender-based
4 (25) 12 (75)
violence
Prevention of unsafe abortion and management of
12 (75) 4 (25)
post-abortion care
Category sexual reproductive health Provided within condom provision 10 (62.5)
services provided in condom provision
services Not Provided within condom provision 6 (37.5)
Health facility offer sexual reproductive Located in the same service site with the same
16 (100%) 0 (0.0)
health services within condom provision provider
services: Offered on the same day 16 (100%) 0 (0.0)

Service providers in the ART clinic and PMTCT room HIV services provided in family planning and condom
(n=16) provision services
Table 2 shows the professional background of service providers. HIV services provided within family planning services ranged
The majority (n=8, 43.8%) were nurses with 1 to 4 years of work from 4 (25%) home-based care providers to 16 (100%) HIV prevention
experience in HIV therapy and family planning service provision information sessions and services to the general population.
(n=9, 56.3%). The mean age of service providers was 34.2 years. However, based on the mean value scored of all components, only
Table 4 [16] shows the information on the service providers and the 9 (56.3%) provided HIV services within the family planning service.
distribution in ART and PMTCT healthcare facilities; 11 (68.8%) Similarly, HIV services provided with condom provision ranged from
were ART supervisors, followed by 5 (31.2%) who were PMTCT 4 (25%) among HIV prevention information services for the general
supervisors (Table 2). population, to 16 (100%) among family planning and prevention, and
Essential sexual reproductive health services are offered management of STI services. On average, 10 (62.5%) HIV services
and integrated with HIV services were provided with condom provision in the study area, as reflected
in Table 4.
The findings reveal that health centers in Oromia Region,
Ethiopia essentially provided sexual reproductive health; family Table 4 illustrates that all health facilities offered sexual
planning, prevention, and management of STIs were provided in all reproductive health services with condom provision services located
health centers, while only 43.8% provided services on the prevention in the same service site, with the same provider, and offered on the
and management of gender-based violence. same day.
When categorized, all components based on total count scored Sexual reproductive health services provided within
greater than or equal to the mean value of 13 (81.2%) health centers PMTCT services
that provided essential sexual reproductive health services, of which Of all components of sexual reproductive health services provided
only 9 (56.3%) provided integrated essential sexual reproductive within PMTCT services, only 2 (12.5%) provided information on the
health services with HIV services. All health centers offered sexual prevention and management of gender-based violence and all 16
reproductive health services within HIV counseling and testing
(100%) provided maternal neonatal care.
services and were located in the same service site with the same
provider and offered on the same day, which accounted for 16 (100%). While categorizing all components based on total count scored
Table 3 indicates that the overall integration of essential sexual greater than or equal to mean value, 15 (93.8%) health facilities
reproductive health services offered with integrated HIV services provided sexual reproductive health services in PMTCT services. All
was provided by 9 (56.3%) health centers, while the programs have health facilities offered sexual reproductive health services within
been provided on the same day with the same healthcare providers PMTCT services located at the same service site with the same
See Table 3. provider and offered on the same day see Table 5.

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Table 5: Sexual reproductive health services provided within PMTCT services in Oromia Ethiopia 2018.
Sexual reproductive health services
Categories Frequency (%) Yes Frequency (%) No
provided within PMTCT services
Family planning 15 (93.8) 1 (6.2)

Prevention and management of STIs 16 (100%) 0 (0.0)

Sexual reproductive health services provided Maternal and new-born care 16 (100%) 0 (0.0)
in PMTCT services
Prevention and management of gender-based
2 (12.5) 14 (87.5)
violence
Prevention of unsafe abortion and management of
15(93.8) 1(6.2)
post-abortion care
Category Sexual reproductive health services Provided within PMTCT services 15 (93.8)
provided within PMTCT services Not Provided within PMTCT services 1 (6.2)
Located in the same service site with the same
Health facility offer Sexual reproductive 16 (100%) 0 (0.0)
provider
health services within PMTCT services
Offered on the same day 16 (100%) 0 (0.0)

Table 6: Structural collaboration with Sexual reproductive health organization and protocols that support integrated service delivery in Oromia Ethiopia 2018.
Structural collaboration with Sexual
Categories Frequency (%) Yes Frequency (%) No
reproductive health and protocols
Capacity building 13 (81.2) 3 (18.8)

SRH services have been reoriented to Links with networks of people living with HIV 11 (68.8) 5 (31.2)
accommodate clients living with HIV Support groups 14 (87.5) 2 (12.5)

Staff training with regards to attitudes 11 (68.8) 5 (31.2)

Monthly meetings 5 (31.2) 11 (68.8)

Structural collaboration (formal arrangement)
Memorandum of understanding 5 (31.2) 11 (68.8)
with Sexual reproductive health organization
Memorandum of agreement 4 (25) 12 (75)
Protocols/guidelines available were ART and family
Protocols/ guidelines support integrated 11 (68.8) 5 (31.2)
planning
service delivery
They are used 11 (68.8) 5 (31.2)

Shortage of equipment for offering integrated services 10 (62.5) 6 (37.5)

Shortage of space for offering private and confidential
12 (75) 4 (25)
services
Constraints for offering linked Sexual Shortage of staff time 10 (62.5) 6 (37.5)
reproductive health with HIV services at this
facility Shortage of staff trained manpower 11 (68.8) 5 (31.2)

Inappropriate/insufficient staff supervision 5 (31.2) 11 (68.8)

Low staff motivation 9 (56.2) 7 (43.8)

Structural collaboration with sexual reproductive health The potential impact of integrated sexual reproductive health,
organization and protocols that support integrated family planning, and HIV services. According to this study, the
service delivery immediate potential impact of integrated sexual reproductive
The reoriented accommodation needed for sexual reproductive health, family planning, and HIV services on the identified service
health clients living with HIV showed that 13 (81.2%) needed capacity dimensions was reported as follow: Costs of services for the facility,
building, and 11 (68.8%) needed links with networks for people living efficiency of services, workload for providers, time spent per client,
with HIV and staff training with regards to attitudes. and equipment, supplies, and drugs were increased by 16 (100%),
12 (75%), 16 (100%), 15 (93.8%), and 10 (62.5%), respectively.
Of all the health facilities, 5 (31.2%) had a formal monthly Conversely, cost services for clients, stigmatization of HIV, and sexual
meeting arrangement, and the same percentage had a memorandum reproductive health clients decreased by 14 (87.5%), 14 (87.5%), and
of understanding. Only 4 (25%) had a memorandum of agreement on 13 (81.2%), respectively (Table 7).
structural collaboration with sexual reproductive health organizations
for people living with HIV. Levels of integrating family planning with HIV services at Health
Centre in Oromia Region. Of total service providers, 14 (87.5%)
The study results revealed that 11 (68.8%) health facilities had provided counseling on family planning methods, methods’ ability
protocols/guidelines that support integrated service delivery and to prevent STIs and HIV infection, and guidance for performing
ART and family planning guidelines, and the same percentage (n=11, risk/intention assessment for pregnancy or spacing for women of
68.8%) were used as a reference during service provision. reproductive age living with HIV.
This study identified constraints in offering integrated sexual It was also found that level of integration of family planning with
reproductive health with HIV services as follow: 10 (62.5%) had HIV services ranged from information on the availability of family
a shortage of equipment for offering integrated services/shortage planning services to the provision of condoms, pills, injectable,
of staff and time, and 12 (75%) had a shortage of space for offering and in some health facilities, the provision of implants in the ART
private and confidential services (Table 6). rooms. However, the level of integration of family planning with HIV

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Table 7: Potential impact of integrated Sexual reproductive health, family planning and HIV services in Oromia Ethiopia 2018.
Impact of integrated services Categories Increase Decrease

Costs of services (facility) 16 (100) 0 (0)

Cost of services (client) 2 (12.5) 14 (87.5)

Efficiency of services 12 (75) 4 (25)

Stigmatization of HIV clients 2 (12.5) 14 (87.5)

The likely impact of integrated Sexual reproductive
health, family planning and HIV services on the Stigmatization of Sexual reproductive health clients 3 (18.8) 13 (81.2)
identified service dimensions
Workload for providers 16 (100) 0 (0)

Time spent per client 15 (93.8) 1 (6.2)

Space and privacy 12 (75) 4 (25)

Need for equipment, supplies, and drugs 10 (62.5) 6 (37.5)

Table 8: Show levels of integrating family planning into HIV services of the onsite provision of contraceptive information, counseling and method options in Oromia,
Ethiopia 2018.
Levels of integrating family planning with HIV services of onsite provision Frequency (%) Yes Frequency (%) No

Guidance for performing risk/intention assessment for pregnancy or spacing 14 (87.5) 2 (12.5)

Counseling on family planning methods, methods’ ability to prevent STI and HIV infection 14 (87.5) 2 (12.5)
Information on family planning method choices available and where to access them, dual protection and
14 (87.5) 2 (12.5)
hormonal methods
Condoms, instructs for and demonstrates correct use 16 (100) 0 (0)

Emergency contraceptive pills 16 (100) 0 (0)

Referral to use other family planning methods not offered onsite 16 (100) 0 (0)

Oral contraceptives with instructions for use 16 (100) 0 (0)

Counseling on potential drug interactions with oral contraceptives 16 (100) 0 (0)

Injectable contraception, with instructions for use and with caution to return on schedule for reinjection
16 (100) 0 (0)
without delay
Intrauterine Device (IUD), with instructions on how to use 0 (0) 16 (100)

Implant with instructions for correct use 5 (31.2) 12 (68.8)

Information on surgical contraceptive methods, with instructions for self- care 0 (0) 16 (100)

services did not include the IUD, with instructions on how to use, or posters visibly reflecting integrated family planning/HIV in the study
information on surgical contraceptive methods, with instructions for area.
self-care in the study area see Table 8.
In 13 (86.7%) of the health facilities, staff was available to provide
Distribution of health managers and supervisors of ART/ family planning counseling and methods throughout the continuum
PMTCT (N=15) of HIV services (such as VCT, ART/PMTCT) and 13 (86.7%) ART
A total census of 15 Health offices/Bureau managers has staff had trained in family planning counseling and method provision
participated in the study, which gave a complete response rate of with ART service provision, as evidenced in Table 9.
100% (15/15). Eight (53.3%) zonal and regional experts stated that the existing
Of all healthcare managers and supervisors who participated services would be able to adopt a level of family planning/HIV
in this study, 6 (40%) were Woreda Health Office ART/PMTCT service integration without compromising the quality of the services
supervisors and 5 (33.3%) were from the primary healthcare unit currently being offered (Table 9).
(Table 9). Evaluation of Integration of family planning/HIV services
Management of integrated family planning/HIV services Finally, the overall integration of family planning/HIV services
According to zonal, regional experts, and Woreda Health Office was evaluated by service providers and services utilizes in order of
supervisors’ ART/PMTCT interviews and checklist observation, priority indicators as follow:
there were no policy barriers for the integration of family planning Services provider-related indicators and evaluation
with HIV services. No budget line for family planning commodities,
The proportion of HIV-related service-delivery points which
instruments, ARV drugs, equipment, and supplies had been
have family planning/HIV integrated services in Oromia Region
established within the HIV health facilities sector in the study area.
health facilities revealed that:
Also, there was no health system financing mechanism to cover
integrated family planning/HIV services. • 15 (93.8%) health facilities provided sexual reproductive
health services in PMTCT services.
Out of all health facilities involved in the study, 7 (46.7%) had
client brochures reflecting messages regarding integrated family • 13 (81.2%) provided essential sexual reproductive health
planning/HIV services, and 10 (66.7%) had messages on the facility’s services.

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Table 9: Management of integrated Family Planning/HIV Services in Oromia, Ethiopia 2018.

Health managers and focal persons of ART/PMTCT Frequency (%)

Regional Health Bureau ART and PMTCT expert and supervisor 2 (13.3)

ZONAL health office ART and PMTCT expert and supervisor 2 (13.3)

Woreda Health Office ART and PMTCT focal person 6 (40.0)

Primary healthcare unit Director 5 (33.3)

Total 15 (100)

Management of family planning with HIV services Yes No

Policies in place that defines health personnel tasks for integrated family planning/HIV service delivery 13 (86.7) 2 (13.3)

Service-delivery guidelines (SDGs) for family planning to be included in ART 14 (93.3) 1 (6.7)

Policy barriers to integrating family planning to HIV services 0 (0) 15 (100)

Financial donors receptive to supporting integration 13 (86.7) 2 (13.3)

The budget line for family planning commodities, instruments, ARV drugs, equipment, and supplies been established within the HIV
0 (0) 15 (100)
sector
Health system’s financing mechanism cover integrated family planning/HIV services 0(0) 15(100)

Client brochures reflect messages integrating family planning and HIV services 7 (46.7) 8 (53.3)

Messages on the facility’s posters visibly reflect integrated family planning to HIV services 10 (66.7) 5 (33.3)

Periodically done through supervision using standardized integrated family planning/HIV service performance tool 13(86.7) 2(13.3)

ART services provide counseling on fertility decision-making and family planning, including family planning method provision 15 (100) 0 (0)
Staffing available to provide family planning counseling and method provision throughout the continuum of HIV services
13 (86.7) 2 (13.3)
(such as VCT, ART/PMTCT)
Reorganize work to accommodate additional tasks of family planning/HIV integration 10 (66.7) 5 (33.3)

ART staff trained in family planning counseling and method provision 13 (86.7) 2 (13.3)

ART staff trained in the system for maintaining a supply of family planning commodities, instruments, and supplies 7 (46.7) 8 (53.3)

Service providers/counselors aware of the current guidelines for contraceptive use by women who are HIV-positive 14 (93.3) 1 (6.7)

Management tools reflect family planning/HIV integrated performance of staff 9 (60) 6 (40)

Service statistics reflect family planning/HIV integrated service activities 13 (86.7) 2 (13.3)

Have family planning commodities, instruments and supplies been added to the HIV services standardized list? 10 (66.7) 5 (33.3)

The mechanism for maintaining a reliable supply of family planning and HIV service needs 9 (60) 6 (40)

The community understands the benefits of integrated services 8 (53.3) 7 (46.7)

Other organizations that you know that provide integrated family planning and HIV services 12 (80) 3 (20)

Ongoing community outreach activities into which family planning/HIV integration awareness activities can be incorporated 6 (40) 9 (60)
The existing services are able to adopt Level family planning/HIV service integration without compromising the quality of the
7 (46.7) 8 (53.3)
services currently being offered

• 9 (56.3%) provided integrated sexual reproductive health • The proportion of HIV-related service-delivery point
services with HIV services. clients who received family planning methods or referral after family
planning counseling was 548 (83.8%).
• 10 (62.5%) offered HIV services and condoms.
• 9 (56.3%) had HIV services that provided family planning • The proportions of female clients of reproductive age
services. attending HIV-related service-delivery points with an unmet need
for family planning were106 (16%).
• The proportion of facilities with personnel trained in
integrated family planning/HIV services were 13 (86.7%) ART staff • The proportion of repeat care and treatment women
who had trained in family planning counseling and method provision of reproductive age living with HIV who reported unintended
pregnancy was 140 (21.4%).
• The proportion of HIV-related service providers who
screened reproductive-aged women living with HIV for family • The proportion of reproductive-aged women living with
planning needs was 14 (87.5%). HIV who reportedly received more than one service were 311 (47.6%)
who received maternal and newborn care, and 233 (35.6%) had
Services utilize-related indicators and evaluation
received family planning in addition to HIV services.
• The proportion of HIV-related service clients who were
screened, counseled, and provided with injectable family planning • The proportion of women of reproductive age living with
was 422 (64.5%); and 151 (23.1%) women living with HIV were HIV who reportedly received more than one service by referral were
provided with an implant in the ART room by trained healthcare 44 (6.7%) to any other services during data collection follow-up care
providers. in the study area.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Sexual Health

Discussion sexual reproductive health combined with HIV services for women
living with HIV. Almost all respondents (n=635, 97.1%) preferred
Integration of sexual reproductive health services with integrated sexual reproductive health and HIV services at the same
HIV treatment facility. Also, most of the providers (n=622, 95%), were in favor of
In this study, 97.1% of the respondents preferred integrated integrated family planning/HIV services.
sexual reproductive health with HIV services at the same facility
or site, and 96.9% preferred to receive sexual reproductive health This study indicated that the integration of family planning
with HIV services from the same providers. This correlates with with HIV services includes counseling on available family planning
the observation made during the study where quite a high number methods in the ART room, to the provision of family planning
of women showed up for integrated services. For example, 64.5% of methods such as condoms, pills, injectable methods, implants in the
ART clients were screened, counseled, and provided with injectable ART rooms, and referrals for long-acting and permanent methods.
contraception, and 80.1% received counseling on informed decision- These study findings showed considerable disparities between the
making and consent for permanent contraceptive methods from availability of elements of integrated family planning/HIV services,
healthcare providers. Only 23.1% of respondents were counseled for and the actual delivery of sexual reproductive health services that
an implant in the ART room. This finding was supported by other are fully integrated; where both HIV- and family planning-related
studies conducted in Lusaka which revealed that more than 80% of elements are actually incorporated into the visit.
respondents accessed family planning services in ART clinics, and
99% used modern contraception of which 60% used male condoms, Recommendation
15% used injectable contraception, and 11% used oral contraceptive • The MOH, in collaboration with others stakeholders, should
pills [13]. The study findings were supported by service providers take the lead and responsibility for ensuring the implementation
who shared that all health facilities offered sexual reproductive health of integrated sexual reproductive health services-including family
services as well as HIV services. The services such as PMTCT, ARTs, planning/HIV services-with chronic care of ART. The involvement of
and contraceptive methods-including condoms-were all located in stakeholders and partners is imperative to guarantee universal access
the same facility offered by the same provider on the same day. The to the integrated family planning/HIV services (HIV prevention,
proportion of services provided at each service-delivery point were therapy, and chronic care) at primary healthcare units.
as follows: 93.8% of health facilities provided sexual reproductive
health services in PMTCT, 56.3% offered integrated essential sexual • The FMOH, the ORHB, and the researcher should organize
reproductive health services with HIV services, 56.3% offered HIV and facilitate a workshop on the developed strategic plans for all
services within family planning services, and 62.5% of HIV services service providers, supervisors, and healthcare managers to enhance
were provided within condom provision reflected in the study area. and scale up integrated family planning/HIV services to different
health facilities in order to ensure its accessibility and availability.
Women of reproductive age attending ART/PMTCT in Oromia
Region, Ethiopia revealed that 54.3% received family planning • FMOH and ORHB should emphasize the integration of
counseling from trained health professionals in the waiting room, sexual reproductive health services-including family planning/HIV
and were referred to the family planning unit within the same facility services-with chronic care of ART, and it should be included as a key
for consultation for long-acting and permanent methods. The study performance indicator. This will help to regularly follow up on the
revealed that 88.8% were referred for implants, 61.3% for IUDs, and activities.
29.1% were for tubal ligation. According to this study, 95% of women
• Engage women in the planning, implementation, and
were satisfied with the utilization of integrated family planning/
evaluation of the integrated family planning/HIV services to
HIV services. This finding was supported by a study conducted in
empower them to decide on their choices regarding family planning/
Tanzania [14], which showed that 85% of clients were screened with
HIV services.
at least one of the three questions on the screening job aid, of which
75% discussed contraceptive methods. Method-specific discussions • Educating clients to increase awareness regarding
increased for condoms 52% to 63%, pills 26% to 62%, injectable 26% the integrated family planning/HIV services by conducting
to 62%, implants 16% to 48%, IUDs 12% to 44%, female sterilization comprehensive health education throughout the sexual reproductive
5% to 19%, and male sterilization 1% to 14% from pre-intervention to health services and chronic HIV care in the waiting room area.
post-intervention. Therefore, in line with the findings of the current
• Self-assessment by service providers and supportive
study, the largest multi-country studies demonstrate significant
supervision by the ORHB to check the quality of counseling according
unmet sexual reproductive health service needs for people living with
to the standard protocols.
HIV attending HIV clinical care facilities. HIV care providers are
uniquely placed to provide reproductive health information, given • Utilizing health extension workers and mother-to-mother
their frequent contact with patients over a long period [15]. support groups to conduct intensive post-test counseling (WHO
2016:246) aimed at strengthening counseling on dual contraceptive
Conclusion
methods for effective protection of women and their partners.
This study assessed the existing integration of family planning Moreover, partners are notified with permission.
services with HIV treatments, guidelines, policy, protocols and
• In line with the WHO (2016:246), more HIV-positive
healthcare managers. This study assessed the existing integration
people should be identified and their early referral to care in some
of sexual reproductive health services with HIV treatment for
settings should be promoted.
women living with HIV and attending ART in the Oromia Region,
Ethiopia. Such integration ranged from the provision of maternal, • Improving the integration of services such as the provision
family planning, neonatal health services, and health education on of ART in antenatal care.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Sexual Health

• Self-management, including personal care assessment Funding

of family planning/HIV service utilization and sexual reproductive
health service utilization plans with ART/PMTCT treatment plans. Funding for this study was obtained from Ambo University.
The university had no role in the design of the study and collection,
• Developing and promoting peer educator and mother-to- analysis, and interpretation of data.
mother support group-based integrated family planning/HIV service
assessment, counseling, and support programs. Author Contributions
• Conducting annual patient satisfaction surveys to DBD contributed to the conception, design, and conduct of
determine their level of satisfaction with integrated family planning/ the study, analyzed and interpreted the data, and prepared the
HIV services. manuscript. RMP contributed to the conception, design, and conduct
of the study, analyzed and interpreted the data, and prepared the
• Conducting outreach services for the underserved, manuscript. DBD contributed to the design and conduct of the study,
including mobile units with health extension workers to minimize analyzed and interpreted the data, and prepared the manuscript. All
transportation by providing one-stop comprehensive services fully authors read and approved the final manuscript.
integrated based on women’s needs.
Acknowledgment
• Community engagement to facilitate women living with
HIV empowerment in terms of integrated family planning/HIV We want to ‘acknowledge UNISA for giving us this opportunity.
prevention, treatment, and care. Our deepest gratitude goes to study participants, ‘Ambo University,
College of medicine and health sciences’, Oromia Region Health
• Expanding integration of family planning/HIV services to Bureau, special zone surroundings of Finfinne Health office,
the primary healthcare-based systems in order to increases availability supervisors, and data collectors for their support. Finally, we would
and accessibility. like to express my gratitude to all participants who volunteered
• Advocating for the mitigation and reduction of harmful participated in the study.
sexual reproductive health and family planning cultural practices. References
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